Can endometriosis cause gross hematuria and dysuria?

Endometriosis Can Cause Gross Hematuria and Dysuria

Yes, endometriosis can cause gross hematuria and pain during urination (dysuria) when it involves the urinary tract, particularly the bladder. 1

Urinary Tract Involvement in Endometriosis

• Urogenital endometriosis is the second most common form of extragenital endometriosis, with the bladder being affected in more than 85% of cases 1
• When endometriosis infiltrates the bladder, it can present with various urinary symptoms including dysuria, hematuria, and irritable bladder syndrome 1
• Bladder endometriosis may cause cycle-dependent or cycle-independent urinary symptoms 2

Clinical Presentation of Bladder Endometriosis

• Common symptoms include:
  • Dysuria (painful urination) 3, 4
  • Gross hematuria (visible blood in urine), which may worsen during menstruation 3, 1
  • Urgency and frequency of urination 3, 5
  • Hypogastric pain 3
  • Urinary incontinence in some cases 5

Diagnostic Considerations

• When a woman of reproductive age presents with hematuria and dysuria, especially if symptoms worsen during menstruation, endometriosis should be included in the differential diagnosis 4, 1
• Cystoscopy is considered the most valuable diagnostic test for bladder endometriosis, though definitive diagnosis requires histological confirmation 3
• Expanded protocol transvaginal ultrasound (TVUS) studies can help identify and map deep endometriosis, including bladder involvement 6
• CT urography is the preferred imaging modality for comprehensive evaluation of the urinary tract in patients with hematuria, with MR urography as an alternative if CT is contraindicated 7

Important Clinical Distinctions

• Gross hematuria has a high association with malignancy (30-40%), requiring a full urologic workup to rule out cancer 6
• When evaluating hematuria in women of reproductive age with pelvic pain, endometriosis should be considered as a potential cause 1
• Do not attribute hematuria solely to antiplatelet or anticoagulant therapy without further investigation 7

Management Approaches

• Treatment options for bladder endometriosis include:
  • Hormonal therapy such as progestins, GnRH agonists, or oral contraceptives 6, 4
  • Surgical excision of endometriotic lesions for definitive treatment 6, 1
• For women with endometriosis who have urinary symptoms, referral to a specialist with experience in managing endometriosis is recommended 2
• If gross hematuria is present, urgent urologic referral is mandatory regardless of suspected cause, as malignancy must be excluded 7

Clinical Pearls and Pitfalls

• Intravesicular endometriosis can occur even with stage I (minimal) endometriosis, suggesting mechanisms of dissemination other than direct bladder infiltration 4
• Endometriosis should be considered in the differential diagnosis of urinary symptoms in young, premenopausal women, especially when symptoms are cyclic or worsen during menstruation 2
• The absence of infection markers in a patient with hematuria increases concern for malignancy or other serious pathology, necessitating thorough evaluation 7